Transcript Trauma Informed Practice - Tri

A workshop for service organizations
and providers to learn about traumainformed practice/care

Defining trauma and its’ elements
 Who can trauma reach?
 Types of trauma

The Fallout of Trauma

“Impacts of Trauma” Continuum
 From Traumatic Stress to Complex PTSD





Co-Occurring Disorders


Substance Abuse and Trauma
The Biological Bases of Trauma Responses



Three elements of PTSD
Predictors of Complex PTSD
Video: “The Relationship b/w Chronic and Complex PTSD
Symptoms of Complex PTSD
The role of evolution
The role of the nervous system
The Prevalence of Trauma


Video: What is Trauma Informed Care?
The Difference b/w Trauma-*Informed* Services and
Trauma-*Specific* Services


The 3 Fundamental Ways Standard Practice Clashes
with TIC








But what is Trauma-Informed Care *overall*?
Misdiagnosis
“Militarized” Treatments and Environments
Misdirected Treatments
Non-TIC vs TIC Approaches: Flip chart?
The Resilience of People Affected by Trauma
TIC Asks:
Why use TIC?
Some Benefits of TIC:






TIC Core Values and Goals
Sandra Bloom’s Seven Commitments
Core Elements in TIC Program
TIC General Practice Highlights
Qualities Essential for Service Providers to
have
Video: Summary put to music and photos

Regardless of its source, trauma contains three
common elements:
● It was unexpected.
● The person was unprepared.
● There was nothing the person could do to stop it
from happening.
Simply put, traumatic events are beyond a person’s
control.

INDIVIDUALS:


Individuals of all ages, socio-economic status, cultures, religions and sexual
orientations (including lesbian, gay, bisexual, and transgender) can be profoundly
affected.
GROUPS:

Families can be traumatized by an event happening to one or more of its members.

Communities can be traumatized when events effect any of its members.

Cultures can be traumatized when repeated denigration, attempts at assimilation or
of course something like genocide occurs.

Service providers can be traumatized after hearing the stories and witnessing the
suffering of clients who have experienced trauma.

Institutions and organizations can be negatively impacted when going through times
of significant change or outside scrutiny (i.e., downsizing, restructuring, inquiries)..





Single incident trauma is related to an unexpected and overwhelming event such as an
accident, natural disaster, a single episode of abuse or assault, sudden loss, or witnessing
violence.
Complex or repetitive trauma is related to ongoing abuse, domestic violence, war,
ongoing betrayal, harassment, often involving being trapped emotionally, physically,
and/or financially, even.
Developmental trauma results from early exposure to ongoing or repetitive trauma (as
infants, children and youth) involving neglect, abandonment, physical abuse, sexual
abuse, emotional abuse, witnessing violence or death, and/or coercion or betrayal.
Historical trauma or (Inter-generational trauma) is a cumulative emotional and
psychological wounding over the lifespan and across generations emanating from
massive group trauma. These collective traumas are inflicted by a subjugating, dominant
population.
Intra-generational trauma describes the psychological or emotional effects that can be
experienced by people who live with trauma survivors.
1
2
Traumatic Stress
PTSD
A) Acute and B)
Chronic
3
Delayed PTSD
4
Complex PTSD

A traumatic stress response may include an
involuntary reaction to a situation that is
experienced as highly stressful but the body is
able to fairly quickly regulate itself after the
stressful event.



A) Acute – resolves within 3 months following
event
B) Chronic – Takes longer than 3 months
Post-Traumatic Stress Disorder is a more
significant intrusive response to a traumatic
event. This would include the ongoing
experience of:



1) Reliving of the traumatic events,
2) Avoidance of the reminders of the event and
3) Increased arousal as a result of the event.

Delayed Post Traumatic Stress Disorder would
include all of the symptoms and experiences
listed in the PTSD response but what is
relevant to this response/impact is the
symptoms may occur much later after the
traumatic event has occurred.
 Complex PTSD is at the far end of the continuum
and is characterized by a history of severe, longterm trauma that usually includes exposure to
caregivers who were cruel, inconsistent, exploitive,
unresponsive or violent.
 It is important to be aware that for some people
they may experience numerous events on this
continuum and therefore the impact of the events
becomes more complex.
Complex PTSD has been defined as the result of
prolonged abuse that involves “characteristic
personality changes, including deformations of
relatedness and identity” (Herman, 1992).

More recently, Complex PTSD has been defined as
“cumulative forms of trauma and retraumatization that
deprive victims of their sense of safety and hope, their
connection to primary support systems and community,
and their very identity and sense of self”.
Complex PTSD has also been described as what
“occurs during a critical window of development in
childhood, when self-definition and self-regulation
are being formed” (Courtois & Ford, 2009).
Complex PTSD is more likely to occur:
● the earlier the abuse was,
● the more prolonged it was,
● the closer the relationship with the person
who acted abusively, and
● the more severe the violence.


The relationship b/w chronic and complex
PTSD
https://www.youtube.com/watch?v=sxpu7n_
uR8Y














Emotional:
● Depression
● Suicidal thoughts
● Anger
● Helpless and ineffective
● Worthless
● Guilt
● Shame/self-blame
● Feel like a “bad” person
● Feel unworthy of love and respect of others
● Feel like an outsider/misfit
● Self-hatred
● Fear of authority
● Loss of faith/spiritual self










Behavioural:
● Avoidance of intimate relationships/pursuing
many relationships
● Isolation
● Substance abuse
● Over-engaging in relationships/refusal to
connect to friends and family
● Self-destructive behaviours
● Suicide attempts
● Aggression and hostility
● Breaking the law
● Missing appointments





Cognitive:
● Thoughts of suicide
● Dissociation
● Lack of concentration
● Overthinking


The term “co-occurring disorder” refers to the
abuse/ dependence of substance use and
mental disorders.
Co-occurring disorders are so common with
people affected by trauma that they should be
considered expected rather than an exception.

And they are associated with a variety of negative
outcomes, including high relapse rates,
hospitalization, violence, incarceration,
homelessness and serious infectious diseases (CODI,
2004).


When an addiction is present, assessment should consider any
existing traumatic impacts.
The two issues cannot be separated because they are so closely
interwoven


This demonstrates the strong link between trauma, mental illness
and substance abuse.


. If the person was not dealing with trauma, they would not feel the need
to use substances to cope. One issue triggers the other.
If and/or when the root cause is not addressed, people use substances to
manage the pain and push down the memories and negative feelings
associated with the trauma.
It is important to let people affected by trauma know that it’s
normal to use substances to cope with the overwhelming
emotions, and that help exists for reducing or stopping substance
use and for addressing the traumatic issues.


What is evolution?
What are adaptive mechanisms?

Physical example / Psychological example

stress hormones are the adaptive mechanisms
evolved to prepare our bodies to escape from
danger, or to fight an opponent, or to freeze
(And when the crisis has passed and the stress hormones are no
longer needed, they are broken down).

However, in chronic stress situations when we
are unable to effectively manage our stress
levels, those stress hormones “become toxic” to
the brain ,and amoung other things, interfere
with our ability to learn new things and then
remember what we have learned.
Normal trauma reaction:




The limbic system (located in the midbrain, above the brain stem) acts as our internal
alarm.
When we sense danger, it goes into action and cues the adrenal glands to release
stress hormones.
These hormones increase blood flow to the major muscles, sharpen our senses, and
ready us for a fast response.
When the crisis is over, the body eliminates the stress hormones and we go back to
normal.
Long-term and early trauma:






The limbic system is primed to remain on alert.
With an alarm system stuck on “high,” people impacted by trauma startle easier,
have trouble accurately reading faces and social cues, have difficulty sleeping, and
tend to avoid situations that increase stress.
Since lots of everyday problems increase stress, at least in the short term, problems
pile up. Avoidance of difficulties and the emotional pain that accompanies them can
lead to phobias and other psychological disorders (Linehan, 2012).
The thinking part of the brain, the prefrontal cortex, may find it hard to break in and
help the limbic system calm down.
As well, there may be more activity, as measured by blood flow, to the right
prefrontal cortex, which research has shown to be associated with pessimism and
depression (Davidson et al., 2003).
So thoughts can get stuck in a rut of ruminating on the past, especially the traumatic
past, which in turn keeps the hyperarousal of the limbic system going.
The hippocampus, which is part of the limbic
system and is involved in organizing
memories, is actually smaller in people who
have experienced long-term trauma. Cortisol
causes cell death in the hippocampus.


It is important to remember that these
responses to trauma are involuntary.
We may not have to look out for actual
predators, but loud noises, the look on a loved
one’s face, or a hundred other incidents can
send people impacted by trauma into a tail
spin.
PTSD:
● According to the Canadian Mental Health
Association, about 1 in 10 people in Canada have
been diagnosed with PTSD.
● Most people can experience symptoms without
developing PTSD.
● Canadian research also identifies combat
veterans, peacekeepers, terrorist attack survivors,
and Aboriginal populations as being at a higher
risk to develop PTSD (Sareen et al., 2007).
Canadian Forces:
● Symptoms of PTSD often appear many months or
years after the event(s) that preceded them. Accordingly, it
is estimated that over the next five years, 2,750 service
personnel will suffer from severe PTSD, and 6,000
will suffer from other mental illnesses diagnosed by a
professional.
● 90% of people with PTSD have a co-occurring diagnosis
of depression, anxiety, substance abuse or suicidal ideation.
● Given the present lifetime occurrence of operational stress
injuries (OSI), it is expected that 30% of soldiers who see
combat will present with PTSD or clinical depression.
● “At the moment three quarters of veterans taking part in
Veterans Affairs Canada rehabilitation programs following
their release for medical reasons are suffering from mental
health problems” (Rodrique-Pare, 2011).
Correctional System:
● 80% of women in prison and jails have been victims of
sexual and physical abuse.
● Many adults convicted of violent crimes were physically
or sexually abused as children.
● The majority of those convicted of homicide and sexually
related offences have a history of child maltreatment
(Jennings, 2004).
● At the time of admission, 62% of Correctional Services of
Canada inmates were identified as requiring follow-up
mental health services (Annual Report of the Office of
Correctional Investigator, 2011-2012).
● In the past 10 years, the number of Aboriginal inmates
has increased by 37.3%, while the non-Aboriginal prison
population increased 2.4% (Annual Report of the
Correctional Investigator, 2011-2012).
Refugees:
● For the fifth consecutive year, the number of forcibly
displaced people worldwide exceeded 42 million,
a result of persistent and new conflicts in different
parts of the world. By the end of 2011, the figure stood
at 42.5 million (UN Refugee Agency, 2012).
● In 2011, there were 24,981 applicants for refugee
status in Canada. More than 15,000 of these
applications were finalized (Immigration and Refugee
Board of Canada, 2012).
● Refugees come to Canada primarily from waraffected countries such as Africa, the Middle East and
South America. Between 2000 and 2010, Manitoba
accepted 11,215 refugees at a rate of about 1,100 a year
(Province of Manitoba, 2010).
Immigrants:
● Manitoba marked the arrival of almost 16,000 immigrants
(permanent and/or temporary residents) in 2011 (Citizenship and
Immigration, 2012).
● Manitoba’s top immigrant source countries were Asia, Africa
and the Middle East, Europe and UK, and South and Central
Americas (Province of Manitoba, 2012).
● Newly arrived immigrants and refugees often experienced
trauma in their home countries. As a result, 9% are estimated to
have PTSD, and 5% suffer from clinical depression.
● Of those who present with depression, 71% also have PTSD.
● Physicians are encouraged to look for sleep disorders, social
isolation, and other signs of underlying trauma, rather than
probing for details which could be re-traumatizing.
● Before referring to direct services targeting trauma, focus on
practical help with regard to settlement and building up
relationships of safety (Rousseau et al., 2011).
Sexual assault:
● There were 22,000 reported sexual assaults in
Canada in 2010 (Statistics Canada, 2011).
● According to General Social Survey, nine out
of ten sexual assaults are not reported
(Statistics Canada, 2011)
● One in four women will be sexually
assaulted in their lifetime (Sexual Assault
Canada, 2012).
Partner Violence:
In 2009…
● Six percent of Canadians with a current or former spouse reported being physically or sexually
victimized by that spouse.
● Similar proportion of males and females reported having experienced spousal violence in the
previous five years.
● Many victims of spousal violence reported recurring incidents. Slightly less than one-half of victims
who had experienced an incident of spousal violence in the previous five years stated that the
violence had occurred on more than one occasion. Females were more likely than males to report
multiple victimizations, at 57% and 40%, respectively.
● Younger Canadians were more likely to report being a victim of spousal violence than were older
Canadians. Those aged 25 to 34 years old were three times more likely than those aged 45 and older to
state that they had been physically or sexually assaulted by their spouse.
● Those who self-identified as gay or lesbian were more than twice as likely as heterosexuals to report
having experienced spousal violence, while those who self-identified as bisexual were four times more
likely than heterosexuals to self-report spousal violence.
● Aboriginal women (First Nations, Inuit and Métis) are more than eight times more likely to be
killed by their intimate partner than non-Aboriginal women (Status of Women Canada, 2012).
● Close to one in five Canadians aged 15 years and older (17%) reported that their current or expartner had been emotionally or financially abusive at some point during their relationship, a
proportion similar to 2004.
● Emotional abuse and/or controlling behaviour are often pre-cursors to violence in a relationship.
● Emotional or financial abuse was 2.5 times more common between partners than physical violence.
Both women and men reported emotional and financial abuse.
● Being called names or being put down is one of the strongest predictors of family violence.
Child Abuse:
● Police-reported data indicate that children and youth under the age of
18 were most likely to be sexually victimized or physically assaulted by
someone they knew (85% of incidents).
● Nearly 55,000 children and youth were the victims of a sexual offence
or physical assault, about three in ten of which were perpetrated by a
family member.
● Six in ten children and youth victims of family violence were assaulted
by their parents. The youngest child victims (under the age of three years)
were most vulnerable to violence by a parent.
● The rate of family-related sexual offences was more than four times
higher for girls than for boys. The rate of physical assault was similar for
girls and boys.
● According to the Canadian Incidence Study of Reported Child Abuse
and Neglect 2008, which consisted of reports from Child Welfare workers,
substantiated cases of child abuse broke down in the following
percentages:
◆neglect: 34%
◆exposure to intimate partner violence: 34% ◆physical abuse: 20%
◆emotional maltreatment: 9%
◆sexual abuse: 3%
Older Adults:
● 2,400 reported violent crimes against seniors (ages 65
and over) were committed by a family member.
● The only violent offence for which senior females
experienced higher rates than males was for sexual
assault.
● Senior women experience higher rates of family
inflicted abuse.
● Most senior victims know the person behaving
violently.
● An adult child and/or spouse commit most family
violence against seniors.


Trauma Informed Care (on Vimeo)
http://vimeo.com/83703534
Trauma-*Informed* Services



Trauma-*informed* services take into account an
understanding of trauma in all aspects of service delivery
and place priority on the individual’s safety, choice, and
control.
Utilizing a trauma-*informed* approach does not
necessarily require disclosure of trauma. Rather, services are
provided in ways that recognize the need for physical and
emotional safety, as well as choice and control in decisions
affecting one’s treatment.
In trauma-*informed* services, safety and empowerment for
the service-user are central, and are embedded in policies,
practices, and staff relational approaches.
Trauma-*Specific* Services
 Trauma-*specific* services more directly
address the need for healing from traumatic
life experiences and facilitate trauma recovery
through specialized counseling and other
clinical interventions. They include specific
therapies such as trauma-focused cognitive
behavioral therapy and other approaches.

Mental Health Treatment that incorporates:


An appreciation for the high prevalence of traumatic
experiences in persons who receive mental health
type services.
A thorough understanding of the profound
neurological, biological, psychological, and social
effects of trauma and violence on the individual.

1) Misdiagnosis
 Among the major sets of symptoms with PTSD are phobia
and general anxiety, substance abuse, depression,
psychosomatic complaints, an altered sense of time
(especially among children), grief reactions and obsessions
with death, feeling guilty, and increased interpersonal
conflicts.
 Because these symptoms are so often associated with other
disorders (ie. Major Depression, Generalized Anxiety
Disorder, Oppositional Defiance Disorder, Bipolar,
Personality Disorders, etc.), what is actually a form of PTSD
gets mislabeled as one or a complex of these diagnoses and
(in the end) treatment is less effective.
 Fortunately, with proper diagnosis and treatment these other
features are much more likely to diminish.

2) “Militarized” Treatments and Environments
 The standard types of environments set up for those
accessing mental health type services often end up
mirroring the abusive “power and control”
relationships that bought them to seek treatment in the
first place.
 Misbehaviours are generally punitive or are dealt with
by employing measures that involve restriction (ex?)
 These types of responses to misbehavior often only
serve to foster a climate of *further* mistrust and
resentment for the traumatized person.

3) Misdirected Treatments
 TIC recognizes that the majority of PTSD symptoms
(Anxiety, depression, substance abuse, relationship
problems) are actually natural reactions undertaken to
self-preserve in the wake of the trauma.
 Think about why the following adaptations might have
evolved. How might their symptoms might effectively
“aid” the person in dealing with their situation?




Anxiety
Depression
Substance use
Lack of trust

Too often, programs focus so intently on the
problems that they miss the strengths and
resilience people bring to the human service
setting.

The most common approaches used by health
care providers highlight pathology or illness, and
inadvertently give the impression that there is
something wrong with a person rather than that
something wrong was done to the person (Elliot et
al., 2005).

Trauma should be viewed as an “injury” that
requires time and support to heal. It can be
very challenging for individuals affected by
trauma to believe that their experience does
not define them or their lives, and that the
trauma did not occur because there was
something wrong with them.

And validating resilience is important, even when
coping behaviours are now causing problems.



Understanding a symptom as an adaptation reduces
the guilt and shame that is so often associated with
trauma.
It also increases a person’s capacity for selfcompassion, and provides a guideline for developing
new skills and resources so that new and better
adaptations can be developed for the current situation
(Elliot et al., 2005).
The language we use when speaking with or about
people who have experienced trauma should also
reflect resilience rather than simply being a description
of them.


Working from a resilience-minded perspective
helps people who have experienced trauma to
realize that they do have the skills they need to
heal and recover.
To identify and access these skills, they need to
reframe their coping behaviours and
knowledge from weakness to strength.

.



Is substance abuse self-destructive or an
attempt at self –medication and healing?
Are “disorders” and symptoms of disorders,
simply normal responses to abnormal
traumatic events? Are they, in fact, the
“solution” rather than the problem?
Is trauma the problem?


90% of mental health clients have been exposed
to trauma, and in the general population, 61%
of men and 51% of women reported at least one
lifetime traumatic event (the majority reporting
more than one).
Therefore it needs to be presumed that the
clients we work with have a history of
traumatic stress and use “universal
precautions” by creating trauma-informed
systems of care.

Emphasis on respect /collaboration


Respect activates resilience
Disrespect activates power struggles
 “I don’t care how much you know until I know how
much you care”.

Lower staff turnover

Staff less likely to avoid or be triggered by client
trauma






Primary goals are empowerment and recovery
Client is viewed as the expert and a resilient
strong survivor
Client is an active planner and participant
Takes a contextual view to problems and
solutions.
Aligns with values of self-determination and
dignity and self-worth
Utilizes the strengths perspective and multisystemic assessment and intervention

● Non-violence
 – helping to build safety skills and a commitment to a
higher purpose

● Emotional intelligence
 – helping to teach emotional management skills

● Social learning
 – helping to build cognitive skills

● Open communication
 – helping to overcome barriers to healthy
communication, learning conflict management,
reducing acting out, enhancing self-protective and selfcorrecting skills, teaching healthy boundaries

● Democracy
 – helping to create civic skills of self-control, self-
discipline, and administration of a healthy authority

● Social responsibility
 – helping to build social connection skills, establish
healthy attachment relationships, and establish a sense
of fair play and justice

● Growth and change
 – helping to work through loss and prepare for the
future






Memory identification, processing and
regulation
Anxiety management
Identification and alteration of maladaptive
cognitions
Interpersonal communication and social
problem solving
Direct intervention in the home/community
Appropriate use of medication





● Build relationships based on respect, trust
and safety.
● Use a strengths-based perspective.
● Frame questions and statements with
empathy, being careful not to be judgmental.
● Frame the client’s coping behaviours as
ways to survive, and explore alternative ways
to cope as part of the recovery process.
● Respond to disclosure with belief and
validation that will inform practical issues
related to care (Havig, 2008).





● Help the client regulate difficult emotions before
focusing on recovery.
● Acknowledge that what happened to the client
was bad, but that the client is not a bad person.
● Recognize that the client had no control over
what happened to them
● Provide an appropriate and knowledgeable
response to the client that addresses any concerns
they may have about the services offered to them,
and then use this knowledge to guide service
delivery.
● Watch for and try to reduce triggers and trauma
reactions.














Empathy
Compassion
Able to Talk Openly
Self-Aware
Self-Care and Wellness
Flexible
Comfortable with the Unknown
Willingness to Learn from Clients
Willingness to Connect Emotionally with the Client’s
Experience of Trauma
Willingness to Step into the World of the Client
Able to Regulate Own Emotions
Able to Treat the Client as an Equal and Collaborator
Good Listener
Willingness to Debrief


Trauma Informed Care 2
https://www.youtube.com/watch?v=djygdr8
FRvA